PELVIC MASSOF OVARIAN/ADNEXALORIGIN

By Ezmeer Emiral

Differentials Diagnosis

Ovarian

Adnexal

Uterine

Gastrointestinal

Bladder,Kidney,Peritoneal

OVARIAN

Benign Ovarian Neoplasm

Malignant Ovarian Neoplasm

Physiological Cysts

Physiological cyst

This groups includes follicular,corpus lteal and theca luteal cystUsu <5cm, have thin wall and well encapsulatedUsu unilocular & contain clear fluid

Follicular cystResults from unruptured Graafian follicle/failure of atresia in non-dominant follicleSeldom >5cm (May achieve up to 10cm)Thin wall + well encapsulatedMay resolve spontaneouslyf/up every month for 3 months; US guided asp/ laparoscopy

Corpus luteum cyst – progesterone prod Occurs when corpus luteum cyst become ruptured or bleeding

occurs into it and subsequently fails to regress Size similar to follicular cyst and usually regresses with time Patient can present with acute abdomen if bleeding occurs and

the cyst rupture. Treatment:Analgelsia /surgery

Theca luteal cyst-associated with multiple pregnancy.Most resolved

spontaneously.

OVARIAN TUMOURS

Benign epithelial tumours

Serous & mucinous cystadenoma

Brenner tumour

Endometriod cystadenoma

Benign germ cell T

Mature teratoma

Dermoid cyst

B. Sex cord stromal T.

Theca cell

Sertoli- leydig tumour

Granulosa cell

Malignant

PRIMARY: Epithelial cell Germ cell Sex Cord StromaSECONDARY: Metastatic eg: Krukenberg

tumour

40+ years

Epithelial Tumours

Arise from the simple cuboidal surface epithelium of the ovary

Account for 80-85% of all ovarian tumours

Classified according to the following histological subtypeo serous o mucinous o endometrioido clear cello Brennero undifferentiated.

Each subtype can be classified as benign, borderline (low malignant potential, LMP), or malignant (invasive).

Usu found in postmenopausal women (mean presentation age is 56 years )

Benign (60%)

- unilocular single layer of flattened or

cuboidal epithelium and the absence of mitoses.

Cyst fluid is clear, thin and colourless.

Papillae formation Malignant (25%)

multiloculated partially cystic, partially solid

tumours with friable papillae. Capsule smooth or irregular or

show papillary projections.

Benign (25%) Single layer of tall, columnar

cells Unilateral, multilocular The cyst fluid is thick,

yellow ,glutinous + mucin-producing cells

Malignant Solid CA in the wall Columnar cell, mitoses

serous tumours mucinous tumours

Papillary serous cystadenocarcinoma Composed of solid tissue and has invaded outside of the ovary, with papillations seen over the surface.

Papillary serous cystadenocarcinoma. Note the many papillations on the inner surface.

Germ Cell Tumours

Derived from primitive germ cells of the embryonic gonad, and may undergo germinomatous or embryonic differentiation.

Affecting young women (peak incidence is early 20s accounting for more than 50 % ovarian tumour of this age group)

TERATOMA (dermoid cysts)• Unilocular cyst (<15cm)• Contain sebaceous glands, teeth, hair, nervous tissue, cartilage, bone, resp & intestinal & thyroid tissue• Long pedicle, heavy & easily undergo torsion• Histologically, a variety of mature tissue elements may be found. • Most common presentaion is acute onset of pain &sudden onset nausea

Opened mature cystic of ovary. A ball of hair & mixture of tissue

Bilateral mature cystic teratoma

Sex Cord Stromal Tumours

Develop from the gonadal stroma Account for 5-10 % of all ovarian neoplasms Subdivided into the following clinicopathological entities:

Granulosa cell tumour Theca cell tumour Sertoli-Leydig cell tumour - Ovarian Fibroma – Meig’s syndrome: ascites, pleural eff, fibroma – 1%

estrogen producing tumour

androgen producing tumour

Granulosa cell tumour has nests of cells which are forming primitive follicles.

Granulosa cell tumour with variegated cut surface.

• Derived frm the ovarian stroma and mostly malignant.

• Produce large amounts of estrogen.• Accelerated skeletal growth &

appearance of sex hair• 5% (children) – precocious puberty• 60% (childbearing age) – irreg menses• 30% (post-menopausal) – PM bleeding

Estrogen excess causes hyperplasia of:

1. Myometrium ~ enlarged uterus

2. Endometrium ~ irreg bleeding. Occ amenorrhea

3. Mammary gland tissue ~ enlargement, tender breast

Metastatic Tumours

Most common: from breast carcinomaalso from: colon ca

endometrial caKrukenberg tumour 1° growth : stomach, Age 30 – 40 yrs Clinically silent Bilat, equal size, mobile, smooth & lobulated HPE : very cellular stroma

: signet-ring appearance + clear mucin- filled cytoplasm

Metastatic adenocarcinoma to ovary appears as a large mass and resembles a primary tumor: Seen here extending out of the pelvis at autopsy is a large right ovarian mass. Metastases are also present in the lower right portion of liver.

Krukenberg tumor of ovary

Adnexal/Tubal

Endometrioma

Hydrosalphinx

Tubo-Ovarian Abcess

Endometrioma/ endometrioid cyst Part of the condition known

as endometriosis. Commonly seen in nulliparaous/women

of reproductive years.It may cause pelvic pain associated with menstruation.

‘Chocolate cyst’, often filled with dark, reddish-brown blood, may range in size from 0.75-8 inches

Th cyst arise from recurrent bleeding from endometric foci placed within substance of ovary.

Hydrosalphinx

Tubal masses that – a long-term sequale of pelvic inflammatory disease.

The tubes are dilated & distended with clear fluid.

Hydrosalpinx fluid is highly embryotoxic and is a likely cause for the decreased fertility in women with a hydrosalpinx. In fact, spontaneous abortion risk is doubled.

Tubo-Ovarian Abcess

Collection of pus and bacteria within the part of the fallopian tube.

Symptoms  include lower abdominal pain, back pain, vaginal discharge and fever.

Treatment includes antibiotic and NSAIDS.In severe abcess may require narcotic pain medication and drainage of abcess/surgery.